hard · NCLEX-RN physiological
The nurse is preparing to administer the ordered cryoprecipitate and platelets to the client. Sequence the clinical actions in the safest order from first to last. Apply the response specifically to this case: disseminated intravascular coagulation secondary to acute promyelocytic leukemia with microthrombi, consumptive bleeding, serial coagulation studies, and component support.
- Confirm the provider's transfusion orders, verify that signed informed consent is in the medical record, and obtain baseline vital signs.
- Perform a dual-RN bedside check of the client's identity, blood band, and component bag labels against the medical record.
- Spike and prime the blood administration tubing with 0.9% Normal Saline only, and initiate the cryoprecipitate transfusion.
- Remain at the bedside for the first 15 minutes of the infusion to assess for acute transfusion reactions.
- Flush the line with 0.9% Normal Saline upon completion of the cryoprecipitate, and prepare the line for the platelet transfusion.
- Obtain post-transfusion vital signs and document the volume infused, client tolerance, and blood product identifiers.
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